Quality of documentation of electronic medical information systems at primary health care units in Alexandria, Egypt

Abstract

Limited data are available about the implementation of electronic records systems in primary care in developing countries. The present study aimed to assess the quality of documentation in the electronic medical records at primary health care units in Alexandria, Egypt and to elicit physician's feedback on barriers and facilitators to the system. Data were collected at 7 units selected randomly from each administrative region and in each unit 50 paper-based records and their corresponding e-records were randomly selected for patients who visited the unit in the first 3 months of 2011. Administrative data were almost complete in both paper and e-records, but the completeness of clinical data varied between 60.0% and 100.0% across different units and types of record. The accuracy rate of the main diagnosis in e-records compared with paper-based records ranged between 44.0% and 82.0%. High workload and system complexity were the most frequently mentioned barriers to implementation of the e-records system. RÉSUMÉ Les données disponibles sur la mise en oeuvre de systèmes de dossiers électroniques en soins de santé primaires dans les pays en développement sont limitées. La présente étude visait à évaluer la qualité de la documentation des dossiers médicaux électroniques dans des unités de soins de santé primaires à Alexandrie (Égypte) et à recueillir les commentaires des médecins sur les obstacles et les leviers ayant un impact sur le système. Des données ont été recueillies au sein de sept unités sélectionnées aléatoirement dans chaque région administrative ; puis dans chaque unité, 50 dossiers au format papier et leurs dossiers électroniques correspondants ont été sélectionnés aléatoirement pour les patients qui avaient consulté dans l'unité de soins au cours de trois premiers mois de l'année 2011. Les données administratives étaient presque complètes dans les dossiers au format papier et au format électronique, mais l'exhaustivité des données cliniques variait entre 60 % et 100 % en fonction des unités de soins et du type de dossiers. Le taux d'exactitude du diagnostic principal dans les dossiers électroniques par rapport aux dossiers papiers était compris entre 44,0 % et 82,0 %. Une lourde charge de travail et la complexité du système étaient les obstacles les plus fréquemment cités à la mise en oeuvre du système de dossiers électroniques.

Quality of nursing documentation: Paper‐based health records versus electronic‐based health records

“…Nursing documentation is a major clinical source for the patient's condition, and it plays an important role in evaluating effective care delivery; therefore, it should be based on solid scientific nursing knowledge which is fundamental for the nursing profession (Noureldin et al., ). Improving nursing documentation is an urgent need in nursing and medical practice (Asamani et al., ).…”

“…Documentation can be either paper‐based or electronic‐based, as per the electronic health records (EHRs), which include all information related to patient care. Regardless of the method of documentation, nursing documentation has to be conducted at the highest standard, to ensure the delivery of safe and high‐quality healthcare services (Noureldin, Mosallam, & Hassan, ). A high quality of nursing documentation is expected in every area of care and in every setting (Wilson et al., ); it is considered an important responsibility of nursing, to ensure the continuity of effective patient care (Asamani, Amenorpe, Babanawo, & Ansah Ofei, ) and to improve patients’ outcomes (Stevenson & Nilsson, ).…”

E-Health in Egypt

“…45 units implemented e-health first level as backup system while the main functional system is in paper form. The efficiency of this system was studied by Noureldin.M et al [1].…”

Completeness and Accuracy of Information in Diabetic and Hypertensive Patients Family Health Records at Meet-Okba Family Health Centre, Giza, Egypt

“…Medical record assessment checklist: it was formulated by the researcher based on the most relevant items retrieved from selected forms of family folder (e.g. personal data form (11) items, investigation data form (11) items and clinical exam data form (36) items.…”